Hyponatremia Institutional Guidelines

[Aether2000]

We are in the early phases of development of institutional guidelines (for our hospital) for electrolyte abnormalities and the conduct of anesthesia. We have many varying opinions regarding hyponatremia that are very confusing to surgeons and hospital staff alike, making it difficult to know if a particular case will go forward or not depending on the specific anesthesiologist. Do you have any guidelines used in your institution for delaying surgery for correction of hyponatremia?

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[BLADEMDA]

We are in the early phases of development of institutional guidelines (for our hospital) for electrolyte abnormalities and the conduct of anesthesia. We have many varying opinions regarding hyponatremia that are very confusing to surgeons and hospital staff alike, making it difficult to know if a particular case will go forward or not depending on the specific anesthesiologist. Do you have any guidelines used in your institution for delaying surgery for correction of hyponatremia?

I use 130 as my cut-off for elective cases. Anything less than 130 and I'd want a note from IM/Nephrology that patient is reasonably optimized for elective surgery.

For urgent or emergent cases I just go ahead.

How low a Na+ for Elective Surgery?


Preoperative hyponatremia and perioperative complications. - PubMed - NCBI

 

[anbuitachi]

what solutions are you using to maintain hyponatremia in long surgeries? If patient is chronic hyponatremia from whatever reason, lets say Na of 128, what do you people like to give to maintain it?

 

[nimbus]

what solutions are you using to maintain hyponatremia in long surgeries? If patient is chronic hyponatremia from whatever reason, lets say Na of 128, what do you people like to give to maintain it?

LR

 

[Ezekiel2517]

Seems unreasonable to create hospital guidelines regarding this. There are patients who have a baseline Na of 124 and live there everyday. There are also patients who can have a Na that is otherwise within the normal range and are extremely high risk if they have had rapid changes in their Na level within the past 24 hours. Besides being nonsense, making hospital guidelines regarding this only promotes the dumbing down of the practice of medicine which is increasingly prevalent everywhere you look. You need to allow physicians to use their knowledge, training, and minds to make decisions.

 

[Aether2000]

Guidelines are being considered due to the variability in each anesthesiologists interpretation of what is acceptable for elective/urgent/emergent surgery. This is causing chaos with hospital staff, holding area patient care, and surgeons who have to deal with a different opinion each day from differing anesthesiologists on what is an acceptable level of sodium on the same patient whose surgery may be cancelled by some but not by other anesthesiologists. It is exactly what Ezekiel describes are the variables that need addressing in a cogent manner, to avoid the perceived randomness and extreme variability that now exists. It is a problem that may be unique to our institution but there are published guidelines that have been developed by workgroups in the past. My question is whether others on this forum have adopted any practical guidelines for their group. Blade, in his usual logical and comprehensive manner has addressed his rationale nicely on another thread.

 

[anbuitachi]

LR

shouldve picked a lower sodium

 

[dhb]

Guidelines are being considered due to the variability in each anesthesiologists interpretation of what is acceptable for elective/urgent/emergent surgery. This is causing chaos with hospital staff, holding area patient care, and surgeons who have to deal with a different opinion each day from differing anesthesiologists on what is an acceptable level of sodium on the same patient whose surgery may be cancelled by some but not by other anesthesiologists. It is exactly what Ezekiel describes are the variables that need addressing in a cogent manner, to avoid the perceived randomness and extreme variability that now exists. It is a problem that may be unique to our institution but there are published guidelines that have been developed by workgroups in the past. My question is whether others on this forum have adopted any practical guidelines for their group. Blade, in his usual logical and comprehensive manner has addressed his rationale nicely on another thread.

How often do you encounter this that it is such a problem? I've only seen a couple in 10 years.

 

[polar403]

How often do you encounter this that it is such a problem? I've only seen a couple in 10 years.

I see hyponatremia less than 130 at least a couple times a month for elective surgery. If chronic and has been worked up, then we generally proceed. If acute and less than 130, ask the patient about free water intake, etc. and send back to primary care for evaluation and possible optimization.

 

[Psai]

How often do you encounter this that it is such a problem? I've only seen a couple in 10 years.

They are a hyponatremia center of excellence

 

[nimbus]

They are a hyponatremia center of excellence

That is better than butt pus center of excellence.

 

[deleted162650]

They are a hyponatremia center of excellence

Apparently not.

 

[Aether2000]

We have had at least a dozen hyponatremic patients scheduled for surgery in the past 3 months with sodium levels less than 120, with the lowest being 104. The surgeons are aware that these levels need correction but cannot determine how much correction is necessary for elective/urgent surgeries. Hyponatremia is not uncommon. One study found 1 out of 13 patients undergoing major surgery were hyponatremic and another found up to 30% of ICU patients having hyponatremia. Another ( Low serum sodium levels at hospital admission: Outcomes among 2.3 million hospitalized patients ) found 14% of hospitalized patients were hyponatremic and of those, 2.7% had sodium levels of 120-125.

 

[Planktonmd]

If you have to create guidelines for hyponatremia to make surgeons and nurses happy you will need to have 2 values, one for acute hyponatremia (130 maybe) and the other one is for chronic hyponatremia (125 seems reasonable).
By the way I have never seen an anesthesia complication that was attributed to hyponatremia.

 

[Aether2000]

Agree that direct anesthesia complications associated with hyponatremia are few, but there may be symptoms and signs post-op that cannot be distinguished from an anesthetic complication. Also mortality is directly correlated to the degree of hyponatremia.

 

[anbuitachi]

If you have to create guidelines for hyponatremia to make surgeons and nurses happy you will need to have 2 values, one for acute hyponatremia (130 maybe) and the other one is for chronic hyponatremia (125 seems reasonable).
By the way I have never seen an anesthesia complication that was attributed to hyponatremia.

I never had case myself but have heard of people in the department having patients get central pontine, including locked in